Since the discipline expanded during 1970–1990, the number of UK consultant clinical pharmacologists has fallen. This paper describes the results of a questionnaire survey of the work patterns of 53 UK consultant clinical pharmacologists, including 35 (66%) employed by universities and 13 (25%) employed by the National Health Service (NHS). The range of activities undertaken includes: teaching medical students and others the principles of clinical pharmacology and practical therapeutics; research in a wide range of pharmacological and therapeutic areas; patient care, mostly in acute and general hospital medicine and in out-patient clinics; service both locally and nationally on a wide range of committees related to drug therapy; editorial work on learned journals and preparation of written teaching materials, including journal articles, didactic textbooks, reference books, and e-learning materials. The median amount of time that a UK consultant clinical pharmacologist spends on these activities is 50 hours per week; several work more than that. The time is spent as follows: teaching 10%; research 40%; clinical work 30%; policy and administration 12%; editorial work and writing 8%. The numbers of physicians who have been newly registered with the General Medical Council as clinical pharmacologists each year has so far been undiminished, but the number of consultant posts has fallen in 1990–2010. Many trainees therefore leave the discipline when they become consultants.
The historical background to clinical pharmacology as a medical discipline
The modern discipline of clinical pharmacology has its roots in Materia Medica, a subject that took its name from the Latin translation of a first-century five-volume herbal by Dioscorides, (peri hulēs iatrikēs, literally ‘about medical stuff’) [1, 2]. The discipline of pharmacology, preceded only by three other cornerstones of medical science, anatomy, pathology, and physiology, emerged at the start of the 18th century, when it was described by the Reverend Thomas Curteis, in his Essays on the Preservation & Recovery of Health (1704), as a ‘boundless field’. However, it was not until the end of the 19th century that pharmacology and clinical medicine converged, the earliest example of which I am aware being the title of Louis Lewin's textbook on adverse drug reactions, the first of its kind, Die Nebenwirkungen der Arzneimittel. Pharmakologisch–klinisch Handbuch (1881) . The earliest use of the adjectival form of the term ‘clinical pharmacology’, klinisches pharmakologisches, appears in Paul Martini's 1932 monograph Methodenlehre der therapeutischen Untersuchung.
Harry Gold, first Professor of Clinical Pharmacology in Cornell University, appointed in 1947, then brought the term ‘clinical pharmacology’ into more regular use, although other terms, such as ‘human pharmacology’ and ‘applied pharmacology’ were also in use at that time. For example, when Desmond Laurence, working in a Department of Applied Pharmacology, edited the proceedings of a meeting that had been held in London the previous year, he used the title Quantitative Methods in Human Pharmacology and Therapeutics. But the choice of term was settled when in 1960 Walter Dilling used the title Clinical Pharmacology for the 20th edition of Materia Medica and Therapeutics. An Introduction to the Rational Treatment of Disease, first published by John Mitchell Bruce in 1884. Coincidentally, in 1960, Laurence published the first edition of his own textbook, Clinical Pharmacology.
The subject expanded in the 1960s, culminating in the publication of three seminal reports in 1969 and 1970, from the Clinical Pharmacology Committee of the Royal College of Physicians (RCP) , the World Health Organization (WHO) , and the Conference on Clinical Pharmacology of the US National Academy of Sciences , in each of which the need for clinical pharmacologists to contribute to the use of medicines in health care was highlighted. To quote the 1970 WHO document, ‘The effective and safe use of drugs is seriously impeded by a lack of clinical pharmacologists’.
The numbers of clinical pharmacologists in the UK increased steadily during the 1970s and 1980s, until the number of consultants in the field reached an estimated 70, which at that time constituted 1.8% of the total complement of UK consultant physicians in all specialties. However, during the next 10 years the numbers steadily declined, to an estimated 53 in 2003 , or about 0.8% of the total complement of UK physicians, which during the same time had increased by about 80%, largely due to expansion in the NHS. In 1999, another RCP report on the discipline noted the decline in numbers, and called for ‘a co-ordinated approach to the recruitment, training and retention of clinical pharmacologists in the NHS and Universities, in order to build on the specialty's acknowledged successes’.
The RCP has estimated that the national requirement for clinical pharmacologists is about 440 full-time equivalents, based on service needs (one clinician for each District General Hospital serving a population of 250 000, with an expected annual drug expenditure of £60 million) and teaching needs (one for each 180 medical students in training, of whom there are now 36 000) . While this estimate is not perhaps unreasonable, it is certainly unrealistic. The College acknowledges this, and has instead suggested an expansion of about 10% per annum, which would increase the number of consultant clinical pharmacologists to about 100 within 6 years, an average expansion of 1.5 posts per centre where clinical pharmacology already exists. This could realistically be achieved by increasing to three the numbers in centres that have currently only one clinical pharmacologist and by adding one member of staff in other centres, making poorly staffed centres viable and strengthening the rest.
What do clinical pharmacologists do?
If a call for increased numbers is to be justified, one can legitimately ask what clinical pharmacologists do, how much time they spend doing it, and what contribution their activities make to health care in the UK.
I have elsewhere [12, 13] described in detail the multifarious activities that clinical pharmacologists undertake, which I have described as a waterfront, with depth and breadth, covering drug therapy in complete depth, from individual molecules to individual people and even whole populations, across the whole breadth of diseases and illnesses . I have listed these activities under four categories, using the mnemonic MRCP, the initials of the qualification examination for entry to the Royal Colleges of Physicians (Membership of the Royal College of Physicians), which almost all UK clinical pharmacologists possess. The four categories are mentoring, research, clinical work, and policy; to these I have here added a fifth, scholarly writing and editing. In order to give context to the results presented below, I shall here briefly review all those activities.
Clinical pharmacologists are mentors, offering support and guidance to others, advising and training them. Teaching is an important aspect of this. Teaching in academic clinical pharmacology includes laboratory science and clinical science, encompassing not only the pharmacological aspects, but such subjects, where relevant, as biochemistry, epidemiology, genetics, physiology, statistics, and clinical medicine. Teaching also includes all aspects of practical drug therapy as underpinned by the science of pharmacology. Those taught include research students, both clinical and nonclinical, medical students and doctors in training, senior colleagues in other specialties, pharmacists and nurses. Mentoring also includes sponsoring, protecting, and promoting recognition of one's junior colleagues.
Clinical pharmacologists are researchers. Academic clinical pharmacologists deal with drug-related problems at all levels, from molecular pharmacology to drug therapy in populations, and including all aspects of toxicology. There are no boundaries to the types of clinical research that they, and their counterparts in drug companies, can undertake, because their interests span all medical specialties in which drug therapy is involved. This means that collaborative research is common. Much original research in drug discovery and development goes on in drug companies; clinical pharmacologists play important roles in drug companies and contract research organizations, taking part in all phases of drug development, including pharmacoeconomic assessments.
The methods that are used in this research include not only the tools of pharmacology, but also biochemical, epidemiological, genetic, physiological, and statistical techniques. They may also involve thought experiments, including definition of terms and development of systems of classification.
Clinical pharmacologists are normally physicians and expert prescribers. Indeed, in the UK the accreditation of clinical pharmacologists is overseen by the RCP. A physician is ‘a person who is trained and qualified to practise medicine; esp. one who practises medicine as opposed to surgery’ (Oxford English Dictionary). Not all clinical pharmacologists practice clinical medicine, but those who are employed in academic departments or health-care services mostly work as physicians in general medicine. Some have a special clinical interest, such as hypertension or respiratory disease, which may inform their research. Some are clinical toxicologists, dealing with acute and chronic poisoning, drugs of abuse, and the toxicology of therapeutic and nontherapeutic drugs and chemicals. In outpatient clinics, clinical pharmacologists manage general medical problems as well as patients with suspected medication-related problems. They often receive requests from general practitioners or hospital colleagues for information and advice about such problems.
The clinical and scientific expertise of clinical pharmacologists is also important in the design and conduct of drug trials, at all phases of drug development, whether in academic departments, drug companies, or contract research organizations, and in understanding their implications in drug regulation.
Clinical pharmacologists make policy. ‘Policy’ (Oxford English Dictionary: ‘a principle or course of action adopted or proposed as desirable, advantageous, or expedient’) includes local, national, and international policy related to medicines. This activity takes many forms, such as health technology appraisal, formulary development, medicines licensing, prescribing policies, and development of therapeutic guidelines. It is mostly undertaken part time, for example in membership or chairmanship of committees. In pharmaceutical companies, work that can be listed under this heading includes preparation and assessment of company dossiers during drug development, pharmacovigilance, assessment of the benefit-to-harm balance (‘risk–benefit’ analysis), the development of risk-management policies, and the assessment of drug harms.
A few clinical pharmacologists hold full-time positions in regulatory authorities, such as the Medicines and Healthcare products Regulatory Agency (MHRA), the National Institute for Health and Clinical Excellence (NICE), and the European Medicines Agency (EMA). A few carry out research on medicines policy.
Clinical pharmacologists are also often called upon to give advice outside clinical medicine and areas of medicines policy, and some have set up individual consultancies to provide advice in a wide range of areas related to drug discovery, development, and use. These activities include consultation by pharmaceutical companies and advice in medicolegal cases, such as patent disputes and criminal or civil cases involving medicines or drugs of abuse. They may also be called upon by the media to comment on drug-related events of public interest.
Scholarly writing and editing
As well as preparing research results for publication, clinical pharmacologists prepare written teaching materials, including journal articles, didactic textbooks, reference books, and e-learning materials. They are often editors of learned journals.
A review of UK consultant clinical pharmacologists
In order to discover what UK consultant clinical pharmacologists are currently doing and how much time they spend doing it, I sent a questionnaire (which can be found at http://www.surveymonkey.com/s/SQ6DZGB) to 83 individuals, of whom 56 are consultant clinical pharmacologists (whom I regard as being core clinical pharmacologists) and 13 were either trained as clinical pharmacologists but work in another discipline or are called clinical pharmacologists but do not have a clinical degree (all currently employed); I also included 14 clinicians who have formally retired from posts in clinical pharmacology but who are still active in some capacity in the discipline. I received 55 replies (a response rate of 66%), only two of which were from individuals who were not medically qualified. The other 53 responses form the basis of this analysis. Of these, 42 responses came from the 56 core clinical pharmacologists (75%) in 23 different centres, and some gave extra information about eight others in the core; four did not identify themselves. The universities from which the 83 graduated are shown in Figure 1, expressed as the number of graduates per 100 medical students in each year.
These results therefore reflect the activities of the large majority of core UK consultant clinical pharmacologists.
The distribution by year of first medical degree of the 83 individuals to whom I sent the questionnaire is shown in Figure 2 and the distribution of the 53 respondents in Figure 3. As there is gap of approximately 10 years between first medical degree and becoming a consultant, these data (Figure 2) show the expansion of the discipline during the 1970s and 1980s and its decline since then.
For comparison, Figure 4 shows the same analysis applied to 191 individuals who are currently registered with the General Medical Council (GMC) as being certificated clinical pharmacologists. These data show that there has been no decline at all in the numbers of those who have undergone training during the same period. However, increasing numbers of those trainees have subsequently gone in other career directions, presumably because of the lack of availability of suitable posts.
Of the 53 respondents, all of whom have medical degrees, 43 (81%) also have a science degree; 12 (23%) obtained their science degree before their medical degree.
Of the 53 respondents, 35 (66%) are clinical academics, 13 (25%) are employed by the NHS, four work in regulatory agencies and one in a contract research organization. About one-third work in departments of clinical pharmacology, about one-third in departments of general medicine or medical sciences, and about one-quarter in departments of cardiology. Of the 35 academics, 28 are readers or professors and seven are senior lecturers; all but one also have a contract with the NHS, almost all as honorary consultant physicians. Of the 13 NHS physicians, 10 also have university appointments as honorary professors or senior lecturers. Thus, the vast majority work for both a university and the NHS.
Of the 53 respondents, 40 teach medical students the basic principles of clinical pharmacology and 41 teach practical therapeutics. Most of them also teach other groups, including, most commonly, pharmacists and nurses, but also students undertaking a variety of research degrees (PhD, MSc, BMedSci), pharmaceutical physicians, dentists, general practitioners, junior hospital doctors, and their own trainees. Some also take part in a range of postgraduate training courses, including taught MSc courses. Some are directors of training programmes in clinical pharmacology and therapeutics and are regional training representatives. The median time spent teaching is 5 h per week (range 1–10 h by those who teach regularly). The extent of other types of mentoring could not be gauged.
Of the 53 respondents, 31 said that medical students are also taught clinical pharmacology and therapeutics by others in their departments, and named 43 others who had not been sent a questionnaire, about a half of them junior doctors. Only 13 said that others outside their department also teach the principles of clinical pharmacology. Only 26 said that others outside their department also teach practical therapeutics; only about a quarter of that teaching is delivered by pharmacists. Thus, the bulk of therapeutics teaching in centres in which they are employed is currently undertaken by clinical pharmacologists.
Of the 53 respondents, 38 do research, as follows: 36 do clinical research, 13 in vitro tissue research, 11 ex vivo tissue research, and six animal research. The median time spent in research is 20 h per week (range 2–24).
The topics of research range widely. The most common disease area studied is cardiovascular (28%), including hypertension, stroke, and endothelial function; other areas that were mentioned included diabetes mellitus, respiratory disorders, ageing, and paediatrics (15% in all). The most common clinical pharmacology topics studied are toxicology (including recreational drugs) and adverse drug reactions (including medication errors) (30% in all); other areas that were mentioned included clinical trials, pharmacogenetics, drug discovery, biomarkers, education, monitoring interventions, and prescribing (24% in all).
The respondents listed 102 sources of grant funding obtained in the past 5 years. The main sources were as follows: UK research councils and other government funding bodies (40%, including the Medical Research Council, the Engineering and Physical Sciences Research Council, and Research Councils UK, The National Institute for Health Research, the Department of Health and the Home Office, the Health Technology Assessment programme, the Chief Scientist Office, and The Health and Safety Executive); the British Heart Foundation and the Wellcome Trust (23%); a variety of private charities (15%); and a small number of pharmaceutical companies (10%).
Of the 53 respondents, 39 undertake inpatient work, almost all in acute and general internal medicine. A few work in clinical toxicology. Specific specialties that were mentioned were acute stroke, cardiology and hypertension, chest medicine, diabetes mellitus, geriatric medicine, and paediatric medicine.
Of the 53 respondents, 37 undertake outpatient work, mostly in general medicine, general cardiology, or hypertension. Other areas mentioned were diabetes mellitus and management of lipid disorders, respiratory medicine (e.g. chronic obstructive pulmonary disease), paediatrics, and stroke medicine.
The median amount of time clinical pharmacologists spend in clinical work is 15 h per week (range 2–32 h).
Policy (including administrative work)
Only one of the 53 respondents reported that there is no medicines and therapeutics committee in their area; 26 reported serving on such a committee, eight as chair or vice-chair, and in all of the 23 identified centres the committees are served by at least one clinical pharmacologist. The activities and responsibilities listed included assessment of newly introduced medicines for inclusion in a local formulary (including review of clinical trials data and general review of new medicines), considering individual requests for off-formulary drugs, prescribing audit and electronic prescribing, championing particular interventions, advising the Trust on medicines policy, design of medication charts, and the formulation of emergency clinical guidelines. The median time spent doing all this is 1.5 h per week (range 0.25–4 h).
Other local administrative activities include chairmanship or membership of local prescribing committees and medical safety review groups, information groups, policy and strategy committees, e-learning and e-prescribing committees, clinical research and development committees, nonmedical prescribing groups, steering groups for specific interventions, education groups, research and development groups and networks, and research ethics committees; some are lead clinicians for acute and general medicine. The amount of time spent on these activities was not specified, but some wrote the word ‘lots’, and one specified 8 h per week spent as clinical director for local research and development.
Of the 53 respondents, 28 reported serving on at least one national committee; 37 committees were specifically named and several others alluded to. There were 50 memberships of the committees that are listed in Table 1. The median amount of time spent in this work is 4.5 h per week (range 1–32 h).
Table 1. Examples of national committees on which clinical pharmacologists serve
Committee or institution
Clinical pharmacologists are or have been presidents or chief executive officers of these institutions, or chairpersons of their committees.
Academy of Medical Sciences
Reviewing research regulation
British National Formulary (BNF), Joint Formulary Committee*; Formulary Development Committee*
Providing information and advice about the use and prescribing of medicines
British National Formulary for Children (BNFC), Joint Formulary Committee
Providing information and advice about the use and prescribing of medicines in children
Government advisory committees (e.g. Advisory Committee on Pesticides, Advisory Council on the Misuse of Drugs, All Wales Medical Strategy Group*, Chief Scientific Adviser's Committee; NHS Evidence; see also MHRA and SMC)
Advising government and related bodies
Grant-giving bodies (such as the Medical Research Council, National Institute for Health Research, Wellcome Trust, British Heart Foundation, Asthma UK)
Of the 53 respondents, 36 reported involvement in journal editorial work of some sort, a few as Editors in Chief. Some are also involved in writing and editing didactic textbooks and reference texts. The journals mentioned included those listed in Table 2. Twenty of these have a current impact factor, the median being 4.485 (range 1.384–14.816). The median amount of time spent on these activities is 4 h per week (range 1–20 h).
Table 2. Some journals on which UK clinical pharmacologists have or have had editorial duties
Clinical pharmacology and therapeutics
Adverse Drug Reactions Bulletin
Basic and Clinical Pharmacology and Toxicology
British Journal of Clinical Pharmacology
European Journal of Clinical Pharmacology
Expert Review of Clinical Pharmacology
Journal of Clinical Pharmacy and Therapeutics
Journal of Toxicological Sciences
Therapeutic Advances in Drug Safety
General medicine and medical science
International Journal of Clinical Practice
Postgraduate Medical Journal
Therapeutic Advances in Chronic Disease
Current Vascular Pharmacology
European Heart Journal
International Journal of Stroke
Journal of the American College of Cardiology
Journal of Hypertension
Journal of the Renin Angiotensin Aldosterone System
Recent Patents on Cardiovascular Drug Discovery
Diabetes Obesity & Metabolism
Drugs and Ageing
Archives of Disease in Childhood
This survey of senior UK clinical pharmacologists shows that those who are in full-time employment are engaged in a wide range of tasks in both academia and the NHS. Anyone who undertakes all the activities listed here, and most do, works on average 50 h per week, and several work more than that. The time is spent as follows: teaching, 10%; research, 40%; clinical work, 30%; policy and administration, 12%; and editorial work and writing, 8%. This is consistent with the sample timetables for academic and NHS clinical pharmacologists that I have published elsewhere  and demonstrates that clinical pharmacologists are working longer hours than those for which they are contracted.
There is good evidence that medical students get too little teaching in clinical pharmacology and practical prescribing. The students themselves say that the quality of clinical pharmacology teaching is good ; however, they are not satisfied with either the quantity of teaching or how their prescribing abilities are assessed. Furthermore, they and their senior colleagues believe that new graduates are not well prepared to prescribe. Some of the evidence comes from studies by clinical pharmacologists [16–18], but independent investigators have concurred [19–21].
The extent of continuing professional development in the area of prescribing, for example by general practitioners, has been less well documented. General practitioners are educated by visits and missives from local prescribing advisers (usually pharmacists), inclusion of practice prescribing data as part of annual appraisal, and targets based on prescribing quality indicators in the Quality and Outcomes Framework . The Quality and Outcomes Framework financial incentives may have improved prescribing targets , but it is not clear to what extent these measures improve patient care  or the quality of prescribing. Disappointingly, a systematic review has shown that medication review by pharmacists in either hospitals or primary care does not alter the rates of hospital admissions or all-cause mortality, although it may reduce the number of prescriptions .
There are two ways of providing more therapeutics teaching: first, by appointing more clinical pharmacologists; and secondly, by recruiting those outside the discipline to provide teaching. It is unrealistic to expect that sufficient clinical pharmacologists could be appointed to repair the problem completely, and we therefore need a model for disseminating expertise in clinical pharmacology .
Free text comments at the end of the questionnaire indicated that a major concern is the lack of trainees in the subject, and despite the data shown in Figure 4, which suggest that there is still no shortage of individuals who are interested in undertaking training in clinical pharmacology and therapeutics, there is no doubt that there are too few posts for them at the end of their training. However, they need not be entirely lost to clinical pharmacology, because throughout the history of the discipline trainees have been seeded into other specialties. A core of about 100 clinical pharmacologists would probably be sufficient for most purposes, and some of their trainees, if there were still too few career posts in clinical pharmacology, could carry their training into other specialties, for dissemination of expertise to their specialty colleagues. There is a particular need for general practitioners who are trained in clinical pharmacology, because about 80% of all prescribing occurs in general practice [26, 27]. Other areas that would benefit from input include paediatrics , obstetrics , geriatrics , cancer , and immunology .
These results suggest that research in clinical pharmacology is healthy. Its subject matter ranges widely, and funding is being obtained from a wide range of sources. Some respondents suggested in free text comments at the end of the questionnaire that the model of clinical pharmacology that was so successful during the 1970s and 1980s is no longer as relevant as it was. This is perhaps too pessimistic. There is much that was relevant then that is still relevant. For example, adverse drug reactions  and medication errors  have increasing importance, and monitoring of therapeutic interventions is still often poorly conducted . However, other priorities have arisen. Clinical pharmacology is and always has been a strongly translational discipline [36–38]. The Scientific Management Review Board at the US National Institutes of Health (NIH) has recently recommended the creation of a new NIH centre focused on translational medicine and therapeutics (TMAT) . Perhaps it is time for clinical pharmacologists to add words such as ‘translational’ or ‘systems’ to their titles . They should certainly stress that pharmacology can contribute in a major way to understanding translational processes.
The fact that clinical pharmacologists do a large amount of inpatient and outpatient clinical service work, particularly in acute and general internal medicine, has not been widely recognized until recently, because the statistics hide their contribution under the heading of general medicine. However, their input is now being better documented  and is confirmed by the results of this survey. Indeed, the evidence shows that the amount of acute general medicine being undertaken by those trained in clinical pharmacology and therapeutics is increasing.
Policy, administrative work, and scholarly writing and editing
Clinical pharmacologists undertake a large amount of local and national policy work, and the workload is heavy, because it is perforce distributed among a relatively small number of individuals. They also undertake extensive work as editors and writers of didactic and other scholarly texts.
I am conscious that some UK clinical pharmacologists may not have received notice of the questionnaire, and that there are also some who have become consultant clinical pharmacologists since notice of the questionnaire was first sent out. The questionnaire can still be found at http://www.surveymonkey.com/s/SQ6DZGB, and I encourage any UK consultant clinical pharmacologists who have not yet filled it out to do so.
I am also hoping that it will be possible to translate the questionnaire into other languages and to extend the survey to senior clinical pharmacologists in other European countries.
Consultant clinical pharmacologists undertake a wide range of duties in teaching, research, patient care, policy making, administrative work, and editing and scholarly writing. Under the current consultant contracts in England, Wales, Scotland, and Northern Ireland, most will be contracted to work 40 or 44 h per week (10 or 11 sessions). Most of them are therefore working for more hours than contracted, some many more. There are too few of them to undertake all of their duties to the extent that they would want, particularly in relation to teaching. An expansion of about 10% per annum, which has been proposed by the Royal College of Physicians of London, would increase the number of consultant clinical pharmacologists to about 100 within 6 years, an average expansion of 1.5 posts per centre where clinical pharmacology already exists. This could realistically be achieved by increasing to three the numbers in centres that have currently only one clinical pharmacologist and by adding one member of staff in other centres. This would make poorly staffed centres viable and strengthen the rest. The data collected in this survey suggest that a small increase of this order would be highly cost effective, assuming that all clinical pharmacologists continued working at the same level of activity.
JKA is President Emeritus of the British Pharmacological Society.
I am grateful to Jonathan Bruun and Karen Schlaegel for help in constructing and distributing the questionnaire and in analysing the data. Many of my colleagues in the discipline provided helpful comments and discussion and informed the ideas presented here.